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Emerging Infectious Diseases and Antimicrobial Resistance

Emerging infectious diseases and increasing prevalence of multidrug-resistant infections are persistent global health threats that may result in substantial morbidity and mortality among military personnel deployed to disease-endemic regions.

The Emerging Infectious Diseases and Antimicrobial Resistance (EIDAR) research area supports clinical studies to characterize the etiology, epidemiology, and patient outcomes associated with emerging pathogens and resultant impact on the health and readiness of the U.S. military with the goal of supporting force health protection (FHP) directives. The diverse EIDAR research portfolio addresses a variety of infectious disease threats, such as multidrug-resistant organism (MDRO) wound/trauma-related infections, vector-borne pathogens, and other infectious diseases encountered during military operations worldwide.

A unique capability of EIDAR, the Epidemiology, Immunology and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EpICC-EID) protocol, allows the DoD to be responsive to infectious disease outbreaks. The recent Ebola outbreak highlighted U.S. hospital emergency response challenges in providing appropriate care of affected patients, while preventing spread of this highly contagious disease.  The EpICC-EID protocol was designed to fill critical needs by providing military hospitals with a plan to rapidly respond to public health crises/outbreaks by obtaining clinical outcomes and epidemiologic data critical to informing effective patient care. The EpICC-EID protocol also provides the foundation for executing interventional trials with collaborative research partners to evaluate new diagnostic assays, drugs, or vaccines in Military Health System (MHS) patients.

This past year, the EIDAR team established strategic partnerships with the Global Emerging Infections Surveillance and Response System (GEIS) section at the Armed Forces Health Surveillance Branch and the USU Center for Global Health Engagement (CGHE) to facilitate alignment of EIDAR research efforts with Combatant Command (COCOM) FHP needs. Consultation at the GEIS Business Optimization Meeting resulted in COCOM Surgeons’ endorsement of IDCRP’s plans for establishing new research initiatives to address the Zika virus (ZIKV) threat. Although military service members deploy extensively to areas with ZIKV transmission, current U.S. and DoD policy precludes testing of asymptomatic men for ZIKV infection diagnosis.  As only 20% of ZIKV infected individuals are symptomatic, the risk could be relatively high for asymptomatic male service members to unknowingly transmit ZIKV to sexual partners. In 2017, the EIDAR team was awarded CGHE funds to assess the risk for non-vector (presumably sexual) transmission of ZIKV from service members post-deployment to their non-traveling spouses. The EIDAR team also established a collaboration with the Walter Reed Army Institute of Research (WRAIR) Viral Diseases Branch on a GEIS-sponsored study investigating ZIKV and related illnesses at the Rodriguez Army Health Clinic in Puerto Rico, an operationally important location as it is origin of nearly 50% of all active-duty ZIKV cases. This study will be launched in 2018, expanding the IDCRP’s clinical research network to include a new site in the Caribbean. 

The EIDAR research portfolio includes GEIS-funded retrospective studies that leverage the DoD Serum Repository with the goal of investigating the impact emerging infectious diseases have on U.S. military service member health and operations. One of these serological surveys will examine the risk for military populations to be exposed to tick-borne infections with Borrelia bacteria and development of Lyme disease or related pathologies as a result of outdoor training operations at military installations in disease endemic areas. Another retrospective study in development will evaluate the incidence of coccidioidomycosis among military personnel stationed at installations within disease-endemic areas, including the Pacific Naval Air Station Lemoore, where there is anticipation of increased risk for Coccidioides fungus exposure in MHS beneficiaries in future years due to forthcoming expansion of the station.

During 2017, the EIDAR team was highly engaged in various efforts addressing clinical questions related to military relevant antimicrobial resistance (AMR) issues. In collaboration with the Trauma-Related Infections research area and led by Dr. Katrin Mende (EIDAR Deputy), the Multidrug-Resistant and other Virulent Organisms Trauma Infections (TIDOS MDR/VO) Initiative continued investigations on combat-related wound infections and associated microorganisms. Furthermore, the EIDAR team received IRB protocol approval for a USU medical student Capstone research project to evaluate the impact of bacterial drug resistance and patient co-morbidities on outcomes in MDRO bloodstream infections within the MHS. The EIDAR team is also promoting DoD Combatting Antibacterial Resistant Bacteria (CARB) initiatives to enhance MHS antimicrobial stewardship programs. In 2017, the EIDAR team initiated an AMR/ASP Clinical Research Consortium at military sites worldwide to conduct clinical research addressing knowledge gaps in best practices to promote antimicrobial stewardship.

Military Impact

The EIDAR research area is responsive to the persistent and ever-evolving infectious disease threats impacting the health and readiness of the U.S. military. EIDAR clinical studies address the Global Health Security Agenda and the National Security Strategy requirements for preparedness and response to infectious disease outbreaks. In response to the recent ZIKV outbreak, the EIDAR team is addressing the unique and challenging FHP issue concerning the risk of sexual transmission of ZIKV to spouses of active-duty service members returning from deployments. In 2018 the team will lead new studies examining the impact of emerging pathogens within the U.S., such as Coccidioides fungus and tick-borne Borrelia bacterial species, on the health and readiness of service members engaged in outdoor training activities at disease endemic military installations. The EIDAR team is also conducting microbiological investigations to support development of improved clinical practices to prevent emergence and transmission of difficult-to-treat, multidrug-resistant bacterial and fungal wound infections. Lastly, EIDAR serves as the central coordinator of multi-site studies investigating key clinical knowledge gaps essential for promoting appropriate antibiotic stewardship practices to prevent the emergence and spread of antimicrobial resistance within the MHS.

Highlights \ Key Findings

  • The EIDAR team established strategic partnerships with GEIS and CGHE to align IDCRP operational infectious disease surveillance and research efforts with COCOM FHP needs
  • The EIDAR portfolio recently expanded to include new initiatives addressing the ZIKV outbreak, including a GEIS-funded effort in collaboration with WRAIR to conduct surveillance for ZIKV and other vector-borne illnesses in MHS beneficiaries in Puerto Rico and a CGHE-funded study on the risk for non-vector (sexual) transmission of ZIKV
  • In support of the CARB Initiative, the EIDAR team established an AMR/ASP Clinical Research Consortium aimed at identifying best clinical practices to promote antimicrobial stewardship and is presently developing a survey to understand behavior driving antibiotic prescribing practices amongst MHS healthcare providers
  • With continued Military Infectious Disease Research Program support of the TIDOS MDR/VO Initiative, high impact molecular analyses of antimicrobial resistance patterns are underway to help guide appropriate treatment guidelines for trauma related infections
  • The USU Department of Pathology is developing serologic and molecular methods to improve detection of recently identified emerging Borrelia species that are suspected to cause an under-reported burden of disease


Mende K, Beckius ML, Zera WC, Onmus-Leone F, Murray CK, Tribble DR, on behalf of the IDCRP TIDOS Group. Low prevalence of carbapenem-resistant Enterobacteriaceae among wounded military personnel. U.S. Army Medical Department Journal. 2017; July-September (2-17):12-17.

Yabes JM, White BK, Akers KS, Sanchez CJ, Mende K, Beckius ML, Zera WC, Wenke JC, Murray CK.  In vitro activity of Manuka Honey and Polyhexamethylene Biguanide on filamentous fungi and toxicity to human cells. Med Mycol. 2017 Apr 1;55(3):334-343.

Heitkamp RA, Li P, Mende K, Demons SD, Tribble DR, Tyner SD. Association of Enterococcus spp. with severe combat extremity injury, intensive care, and polymicrobial wound infection. Surg Inf. Dec 20 2017 [Epub ahead of print].


USUHS Student Research Days, May 17, 2017, Bethesda, MD:

  1. Abstract: Vostal A, Chukwuma U, Pelaez G, et al. Antibiotic Resistance and Clinical Outcomes in Bloodstream Infections.

ASM Microbe 2017, June 1-5, 2017, New Orleans, LA:

  1. Poster:  Heitkamp R, Demons SD, Li P, et al. The Diversity of Enterococcus strains from combat wounds and strain-based patient outcomes.

Military Health System Research Symposium 2017, August 27-30, 2017, Kissimmee, FL:

  1. Poster #224: Mende K, Mangum LC, Akers KS, et al. The Multidrug-resistant and other Virulent Organisms (MDR/VO) Initiative: 2017 update.
  2. Poster #234: Mangum LC, Garcia GR, Tribble DR, et al. Biofilm formation capacity among Enterococcus species isolates from clinical wound infections of injured U.S. Military personnel.
  3. Poster #229: Heitkamp RA, Demons SD , Li P, et al. Enterococcus diversity in extremity trauma wounds.
  4. Oral Presentation: Lanteri C, Lalani T, Mende K, et al. The Infectious Disease Clinical Research Program (IDCRP): A Global Collaborative Network Engaged in Operational Clinical Research Addressing Emerging Infectious Disease Threats Within the US Military.
  5. Poster #210: Keasey SL, Rivard RG, Kortepeter MG, Ulrich RG. Proteome-level Comparison of Antibody Responses to Anthrax and Anthrax Vaccines.